The patient improved for a few months but then had a recurrence of intense proctalgia, with the pain occurring upon defecation, which had a very negative effect on her quality of life. Boccasanta et al. (2004) reported that 20% of patients who undergo STARR develop painful defecation. Since my patient refused a temporary colostomy, I sug­gested a period of total parenteral nutrition at home so that her intestine could recover and she would have as few bowel movements as possible. With this approach, the pain was indeed greatly reduced. Follow-up visits included the extraction of a staple from her rectum. However, after 3 months, when she had resumed a normal diet, the severe pain returned. Over a year has passed and the patient is still suffering from proctalgia—all of this the result of an improperly treated anal fissure.

Before the operation begins, we must consider the preparation by the anesthetist. The patient is awake, which means that she has been given spinal anesthesia, placing her at greater risk of urinary retention after surgery. We therefore caution the anesthetist not to give the patient large volumes of intravenous fluids. (If the patient was an elderly man with prostate problems it would be essential that he receive minimal fluids). The first surgical move that we make is one that can easily cause damage, i.e., insertion of the anal retractor (as this is a Ferguson procedure and assessing the rectum is never a bad idea), since we know that the patient has weak sphincters due to her age and multiple deliveries. To avoid stretching the muscle fibers and thereby damage the continence mechanism, it is best to use an instrument that does not overly dilate and is not too wide (< 32 mm), such as a Fansler, Ferguson, or Sapimed Beak dilator (Fig. 2.2). Some surgeons prefer the 36-mm circular anal dilator (CAD) used on PPH. It should be noted that even if the patient were a young male with a narrow anus, we could damage (lacerate) the sphincter by the excessively energetic insertion of a large retractor. It is therefore essential that we choose the right instrument and perform the maneuver delicately. If a Milligan-Morgan procedure is being performed, an anal retractor is not needed.

Continuing our operation: During dissection of the hemorrhoids there will be bleeding, especially if scissors are used or a cold scalpel. Since the less blood the better, we could proceed slowly and coagulate the hemorrhoidal plexus as we go. I use a maneuver (described in “Tricks of the Trade”, below) to reduce intraoperative bleeding which seems to work well and was also mentioned in the chapter on anal fissure. With the tip of a pair of forceps, I touch the tissue, as is done using an elec­trocautery device, to excise the pile. At the same time, the instruments nurse touches the other end of the forceps with the electric scalpel.